21687APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification -
Building Address: -
11G�l 0 7 �53��1y!�
POUAIT NO.
1") 1"t (�
G olUy
�wrel.�.me; one: ,
I E E
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING-ELECTRICAL-PLUMBINGMECMNTCAL
iTAL DATE
_ Z•Z [ 1
C.mmotm'sN.met L6,. f5.4r7-?6,¢ LI n:J N
S10Q �2 [
CATEGORY CONTROL N
BUILDING PERMIT INFO
Architect/Engineer. LM. No:
I
QTY . ELECTRIC PERMIT FEE
Address: / ^ -
I—
❑ ' ❑ ❑, .: �. _
LICP.NSED CONTRACTOR'S_161ECLARATION
I hereby affirm that l am licensed under provisions of Chapte;9 (comment,
Ingwith Section 7000).! Dlvblon3of[he OuNnessand Prof eslonsCode,and my
Ilcense b e fullfora and effect.
License Chs �,iLt. N = OO �-4'
Date I�1g-h,�l Contratlor /-�q�
ARCHITECT'S DECLARATION
I understand my plans shag be used as public records.
Licensed Professional
OWNER -BUILDER DECLARATION --
Iherebyalfirmthatlamexempt fromthe Contractor's Lime" law for the
following reason. (Section 7031.5, Business and Professions Cade: Any city or
manly which requim a permit to romW N, alter, improve, demo)hh, or repair
anystmelom prior to its issuance,ahnmquirm theappliant forsuch permit to
file a signed statement that he h Banned pursuant to the provhlone of the
Contractor's License Law (Chapter 9 (commencing with Section 7000).! n 3 Divi-
doof the Business and Profemiom Code) or that he Is exempt therefrom and
the basis for the alleged exemption. Any violation of Stolon 711115 by any
.ppllcant fora permit subjectathe applicant tot civil penalty of not rom than
Ove hundred dollars ($500).
❑I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure h not intended or offered for
sale (Sec 7044, Basin•.. and Profession Code: The Contract.?. Llama Law
does not apply to an owner of property, who builds or Improves thereon and
whodonsuchwork himself orthruugh hisown employees, provided that such
Improvementaamnwl tendedoroffamdforsale. ILhoweveplhebulidingor
Improvement issold within.neyearofcbmpirtlon,the owner-bullderwlll have
tin�urden of proving that he did not build or improve for purpose of sale.).
LL,,ff 1, ae owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions Code:
The Contractor's License Law don not apply to in owner of property who
Wilda or Improve* thereon, and who contracts for such p pjacts with a
onatradoefs) licensed pursuant to the Contractor's License Law.
0I am exempt under Sec. B A P C for this reason
APPLIANCESRESIDENPIAL
JOB DESCRIPTION
e�
PANELS
201 -IOW AMPS
OVER 1000 AMPS
c -Q• FT. FLOOR AREA
-
$/SQ. FT.
SIGNS ELECTRICAL
SPECIALCIRCUIT/MISC
gFMP. METER OR !'OLE !NST.
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
OUTLE7SSWITCIiFSFTXTIJRES
NEW RESIDENTIALECTR .t•T.
STORIES
TYPECONSTRUCTION
T TOL:
QTY, PLUMB! P 1 T)tFLOOD
'OCC. GROUT'
RES ANTIS
PERMITISSUANCE
ALTER RAIN k VENT
LANE
APN
FEE SUMMARY
' BACK PROTECT. CF.
DRAINS RR
pLXgS .!.RAP K
SANITARY Y_,N—
RECEIPT N
Owner Date
WORKMANCOMPENSATIONDECLARATION
❑ 1 herebP affirm thsl I have a certlRute o! consent 10 aelbinsure, ora
certl(toteat .rken'Comperuati.sImumnmoraadiftedropythemof(Seca
3800, lab C.) '
policy 1
SCHOOLTAX -Y ,N
RECEIPT N
CAS FA. SY 1 .40IfTLEfS
PARK FEE Y N
RFAEBT N
GAS EA. SY ER 4 (FA)
pp��ppaer
BUILDING DIVISION FEES
IYICemned copy 1,i hereby furnished.
,.FL J'I"`-ertined copy 1, filed with the my Inspection division.
CERTIFICATE OF FXEMPEION FROM WORKERS'
COMPENSATION INSURANCE
Co becom
Rhin cectlon need rad be completed ifthepernst SURA bfor ane hundred dollars
($100)orims')
I mdify chat In the performance of the work forwhich this permit i, Issued,
1 shall not employ any person In any manner m as to become subject to the
Workers Compensation laws of California. Date
Applicant
NOTICE TO APPLICANT. 10fur making thh Certlllcale o(Exemptian, you
should become subject to the Workers' Compuuatlon provlalons olehe Labor
Code, you must forthwith comply with such previslmu or this per ut shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there Is a mrutructlon lending agency for the perform.
anceof the work for which this permit is issued (Sec. 3097, Civ. Cd
Lenders Name
Lender's Address
I certilythat l have readthisapplicallonand Nate thattheabovelnformatlon
W coned. l agree to comply with all city and county ordinances and nate laws
relating to building construction, and hereby autho ice representatives of thh
city•toenmrupon theabove.mentioned properyfmirupection purposes.
(We) agree to save, In I(y an d keep harmless the City of Cupertino
agalnnt llabllltles,pdg fib sand expenses which may In anywayaccrue
agains i ity in race ofthe granting oft lepentrut.
..��
SlgnutureofAppll n/Contractor - V DuLte-
HAZARDOUS MATERIAL SCLOSURE
Wllitheappilcant or futum building occupant a orhedleh.rd...
material as deflnedbythe Cupertln.M.melpal Code, peer 9.12, and the
Iic.hhand SafetyCod-e,yl r2S532(a)7
❑ Yes �1S4T Nb .
' Will the applicant utum building occupant use equipment or devices
which emit haeardou.air metarre..Ms as defined by the Bay Area*Air
uality Management Dlatrla7
Yn '
have read the ousrwterials requirements under Chapter 6.95 of
the California Health Safety Code, Sections 25505,25533 and 25534. I
understand that lithe building does not currently have. tenant that it is my
respond bIIty to notify th ant .III, requirements which must be met
priorlo s is of xrtlflce �u ary.`
GREASE/INDUSTHL ASTE INTERCEPTOR
PLANCHECK EEG"
PAID .
Date Rewi t#
GREASETRAP
SEWER -SANITARY -STORM EA. 200FT.
RIOTER [iFATFR W/VFM/F].EC7R
ENERGY FEE Y N
PAID
Date Recei t#
'
WATER SVSIFM/TREATING
NEW RESIDENTIAL PLMB. .FT.
TOTAL:
BUIL12INC
SEISMIC FEE
TOTAL:
ELECTRIC FEE
QTY, MECHANICAL PERMIT FTE
PLUMBING FEE
MECHANICAL PEE
FEES PAID:
4 OD
PERMIT ISSUANCEQ�
ALTPRORADDTOMECH.
Date Receipt#
AIR HANDLING UNIT (TO 10,(N70 CFM)
SUBTOTAL
AIR HANDLING UNIT (OVER 10,000CFM)
CONSTRUCCION TAX -
EXFIAUSTHOOD (W/DUC_'n
CONSTRUCTION TAX PAID:
' HF-ATINGUMT(TO100,000BTIJ V
'
Date Recei f#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN( SINGLE RESID)
ISSUANCE DATE
-
PAW
�A� 4j fy ��Q�
A A 2 97
- ad basses{r�11..
ISSUED BY: t 6l 4lKlhua u'` VI�G
V -
B01LER-COMP OHP OR 100,000 BTU)
BOILER.COMP(OVER 100,000 B7U)
NEW RESIDENTIAL MECJi. SQ.FT
-
.
Uv nerorauthoricedagen Dat
TOTAL: a D -
OFFICE COPY